Implementing the PDH-CPG Across the Deployment Cycle Post OEF/OIF May 2003 (Updated April 2005) - PowerPoint PPT Presentation


Title: Implementing the PDH-CPG Across the Deployment Cycle Post OEF/OIF May 2003 (Updated April 2005)


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Implementing the PDH-CPGAcross the Deployment
CyclePost OEF/OIFMay 2003 (Updated April 2005)
  • pdhealth_at_amedd.army.mil
  • Provider Consult HelpLine 1-866-559-1627
  • Patient Call Center HelpLine 1-800-796-9699

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Training Agenda
Introduction and Guideline Overview LTC Charles Engel
Basics of Risk Communication Tim OLeary
Post-Deployment Health Assessment 2796 Enhanced Process COL Jeff Gunzenhauser
PDH CPG Application Lt Col Adkins, LTC Engel, Mr. OLeary
Summary and Questions
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Why Focus On Post-Deployment Health
Care?(Isnt it just routine health care in a
slightly different uniform?)
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because our workplace may be hazardous to health
History Made Overly Simple Before VietnamLife
Limb After VietnamPost-Traumatic Stress
Disorder After Gulf WarToxic Exposure
ConcernsMedically Unexplained Symptoms
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Gulf War Syndrome
  • 17 of UK Gulf War Veterans believe they have
    Gulf War Syndrome

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Recent Unexplained Syndromes Involving the
Military, War, Deployment, or Terror
  • Dutch peacekeepers in Lebanon (1980s)
  • Jungle Disease (Dutch peacekeepers in Cambodia)
  • Gulf War Syndrome
  • Afghanistan Syndrome (Russia, 1990s)
  • Chechnya Syndrome (Russia, 1990s)
  • Illnesses after 1992 El Al Airliner crash in
    Amsterdam
  • Illnesses after anthrax vaccination (1990s)
  • Dutch peacekeepers in Bosnia (1995-6)
  • Canadian peacekeepers in Croatia (late 1990s)
  • Balkan War Syndrome

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Unexplained Physical SymptomsMedicines Dirty
Little Secret
  • Specialty Clinical SyndromeOrthopedics Low Back
    Pain Patellofemoral Syndrome
  • Gynecology Chronic Pelvic Pain Premenstrual
    Syndrome
  • ENT Idiopathic Tinnitus
  • Neurology Idiopathic Dizziness Chronic Headache
  • Urology Chronic Prostatitis Interstitial
    Cystitis Urethral Syndrome
  • Anesthesiology Chronic Pain Syndromes
  • Cardiology Atypical Chest Pain Idiopathic
    Syncope Mitral Valve Prolapse
  • Pulmonary Hyperventilation Syndrome
  • Endocrinology Hypoglycemia
  • Specialty Clinical Syndrome Dentistry
    Temporomandibular Disorder
  • Rheumatology Fibromyalgia Myofascial
    Syndrome Silicosis
  • Internal Medicine Chronic Fatigue Syndrome
  • Infect Disease Chronic Lyme Chronic Epstein-Barr
    Virus Chronic Brucellosis Chronic Candidiasis
  • Gastroenterology Irritable Bowel Syndrome
    Gastroesophageal Reflux
  • Physical Medicine Mild Closed Head Injury
  • Occupational Multiple Chemical SensitivityMedicin
    e Sick Building Syndrome
  • Military Medicine Gulf War Syndrome
  • Psychiatry Somatoform Disorders

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Institute of Medicine
  • Strategy 5 Implement strategies to address
    medically unexplained physical symptoms in
    populations that have been deployed.

WA, DC, National Academy Press 2000
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A DoD Center of Excellence
  • Deployment Health Clinical Center

Mission Improve post-deployment health care
for DoD beneficiaries
Located at Walter Reed Army Medical Center
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How Can We Do Better?
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DoD-VA CLINICAL PRACTICE GUIDELINE
ONPOST-DEPLOYMENT HEALTH EVALUATION MANAGEMENT
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Post-Deployment Health Clinical Practice
Guideline (PDH-CPG)
  • DoD/VA Post-Deployment Health Evaluation and
  • Management Clinical Practice Guideline
    (PDH-CPG)
  • Evidence-based guideline for the evaluation and
    management of patients with deployment-related
    health concerns/conditions in the primary care
    setting
  • Completed by an expert multi-disciplinary,
    multi-agency panel in 2001
  • Initiated with a worldwide satellite broadcast
    January 2002 and distribution of a Tool Kit to
    all MTFs
  • Replaced Comprehensive Clinical Evaluation
    Program (CCEP)
  • No change since 2002 except modified coding
    guidance

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PDH-CPG Use Mandated by Health Affairs April
2002
All DoD military treatment facilities should now
be using the Post-Deployment Health Clinical
Practice Guideline the military unique vital
sign question Is the reason for your visit today
related to a deployment? should be asked of
every patientproviders will review and employ,
as needed, this guideline during their
evaluations
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PDH-CPG Components
Primary Care Clinic Visit Military Vital Sign
Screening
Post-Deployment Health Assessment DD Form 2796
PDH-CPG
Symptomatic With No Diagnosis Medically
Unexplained Symptoms Algorithm A2
Symptomatic With Diagnosis Algorithm A3
Asymptomatic Concerned Algorithm A1
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Overview of Guideline Features
  • Military-unique vital sign
  • Stepped care framework
  • Risk communication guidance
  • Web-based clinician support
  • Longitudinal care emphasis
  • Data automation features
  • Metrics outcomes monitoring
  • Supporting Center of Excellence

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What Is the Military Unique Vital Sign?
  • All persons should be asked Is your health
    concern today related to a deployment? at every
    primary care visit except wellness visits (e.g.
    periodic exams and preventive care)
  • Patient rather than provider determination
  • Percentage of positive responses
  • lt1 during 2001 testing (Bragg, Lejeune, McGuire)
  • 2.8 AD vs 0.2 FM in NQMP study published Dec 04
  • 5-8 in current data reviews

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Stepped Risk Communication
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Local Challenges
  • Identifying a champion clinical administrative
  • Local gap analysis
  • Implementing the question?
  • Adhering to visit coding?
  • Assessing follow-up metrics?
  • Local Utilization Management/Informatics support?
  • Making provider patient information available
    from the toolkit?
  • Obtaining risk communication training?
  • Receiving DHCC News? Medical Early Bird for
    those who want to know what patients may be
    reading

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Risk Communication Its Relevance for Clinicians
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What is Risk Communication?
  • An interactive process of exchange of information
    and opinion among individuals, groups, and
    institutions. It involves multiple messages
    about the nature of risk and other messages, not
    strictly about risk, that express concern,
    opinions, or reactions to risk messages or to
    legal and institutions arrangements for risk
    managers.
  • National Research Council, Committee on Risk
    Perception and Communication

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What is Risk Communication?(cont.)
  • Building and maintaining relationships based on
    the effective exchange of technical and/or
    scientific information between concerned
    stakeholders about an actual or perceived risk
  • Risk Communication Team, U.S. Army Center for
    Health Promotion and Preventive Medicine

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What is Risk Communication?(cont.)
  • A science-based approach for communicating
    effectively in
  • High concern
  • Low trust
  • Sensitive or
  • Controversial situations
  • Vincent Covello, Center for Risk Communication

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Gaining Trust and Credibility
  • Difficult to gain and easy to lose
  • Most important factors are
  • Empathy
  • Caring
  • Personal Commitment
  • Honesty
  • Openness
  • Expertise

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Risk Communication History
  • Risk communication dates back to 1980s
  • Interact with communities or groups
  • Concern about health, safety, or environmental
    dangers
  • Perception of peril to themselves especially to
    their children

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Seven Rules of Risk Communication
  • Rule 1. Accept and involve the recipient of
    information as a legitimate partner
  • Rule 2. Plan carefully and evaluate performance
  • Rule 3. Listen to your audience
  • Rule 4. Be honest, frank, and open

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Seven Rules of Risk Communication (cont.)
  • Rule 5. Coordinate and collaborate with other
    credible sources
  • Rule 6. Plan for Media influence
  • Rule 7. Speak clearly and with compassion

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Narrowing Risk Communication
  • Until recently, risk communication was used for
    groups and communities
  • In a clinical setting, risk communication is used
    with small groups (e.g., family) or individuals
  • Building trust and credibility remains crucial
  • Fosters a good environment for communicating
    sensitive health risk information
  • Listening is half of communication

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Stepped Risk Communication Strategy
Concerned, Unexplained Symptoms
  • Key element of PDH-CPG
  • Routine primary care assessment
  • routine trust rapport building
  • Ascend risk communication
  • stairs as outlined above

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Clinical Health Guidelines
  • Risk communication is a central part of the
    guideline
  • Routine primary care assessment routine trust
    rapport building
  • Ascend risk communication stairs for
  • Unconcerned patient, but recently deployed
  • Concerned patient with recognized disease
  • Concerned patient who is asymptomatic
  • Concerned patient with chronic unexplained
    symptoms

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Why Use Risk Communication?
  • Allows transmission of relevant accurate health
    information
  • Increases patient provider focus on relevant
    health risks
  • Reduces unnecessary patient distress

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Benefits of Risk Communication
  • Improves patient
  • Acceptance and adherence to medical advice
  • Satisfaction with care
  • Confidence in provider their relationship
  • Trust in the health care system
  • Functioning health behaviors
  • Chances of returning to life roles
  • Improves provider satisfaction with the process
    of delivering care

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What Risks Concern Patients?
  • Risk of serious illness
  • Risk of various outcomes (e.g., cure, death,
    disability)
  • Risks of medical tests
  • Risks of medical treatments
  • Risk of workplace or environmental exposures

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Clinical Risk CommunicationE N V I T E
  • E-mpathy Listen actively. Confirm what you
    hear. Express concern. Convey genuine desire to
    assist.
  • N-on confrontational Subordinate the need to be
    right to the obligation to relieve suffering.
    Dont engage in arguing with patient.
  • V-alidate Validate the patients decision to
    seek care.
  • I-nform Offer data that addresses patients
    specific concerns presented in an understandable
    way.
  • T-ake Action Describe options. Appropriate
    tests/labs. Schedule a follow-up. Research
    concerns. Consider consultation or second
    opinion, as needed.
  • E-nlist Cooperation Negotiate an action plan
    with the patient rather than imposing one on him
    or her.

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Who Needs Risk Communication Expertise?
  • Physician
  • Nurse
  • Desk Clerk/Receptionist

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Risk CommunicationSummary
  • Clinical risk communication involves low
    trust-high concern situations
  • Trust and credibility are the heart of
    communicating health information to patients
  • Value your patients views and beliefs

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Post-Deployment Health Clinical Practice
GuidelineTools Application
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Enhanced PDHA Process www.PDHealth.mil
  • Guidance for Completing
  • DD Form 2796
  • PDHA Policies Directives
  • Deployment Exposures
  • Information
  • Redeployment Briefing
  • PDHA Training Videos

Toolbox DD2796 Primer
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PDH-CPG Web-Based Toolswww.PDHealth.mil
  • PDH Guidelines
  • Overview
  • Guideline
  • Algorithms
  • Implementation
  • Desk Reference Toolbox
  • Tool Kit (Updated by Toolbox)
  • CCEP Transition
  • Broadcast, 30 Jan 2002
  • Supporting Guidelines
  • Clinicians Helpline
  • 1-866-559-1627

Home Page
PDH Guidelines
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PDH-CPG Desk Reference Toolbox
  • Desktop-sized Laminated Box
  • Desk Reference Cards
  • Compact Discs
  • Interactive PDH-CPG
  • MEDCOM CD of Other CPGs
  • 2 PDH-CPG Training CDs
  • Sample Clinician and Patient
  • Brochure
  • Vaccine Healthcare Centers
  • Immunization Tool Kit

Contents on www.PDHealth.mil
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Deployment Cycle Support (DCS)Scenario - 12 May
03
  • Personnel and situation
  • SSG Ira Freedom
  • 29 y/o male stationed at Ft Carson
  • Married, wife (Patience), 8 y/o son, 4 y/o
    daughter
  • In SWA for 90 days
  • In Kuwait and Iraq as part of OEF and OIF
  • Saw 2 weeks in combat, including heavy resistance
    in Baghdad urban warfare
  • No significant medical history prior to
    deployment
  • Anticipates redeployment on 15 May

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Deployment Cycle Support (DCS)Scenario - 12 May
03 (cont.)
  • SSG Freedoms friends in Iraq
  • Formed bond due to similar history
  • SSG Reserve, a mobilized reservist
  • Mr. Seville, a deployed federal civil service
    employee
  • Ms. Cross, a Red Cross Volunteer
  • Ed Itor, an embedded journalist
  • All going back on 15 May
  • SSG Natalie Guard, a mobilized National Guard
    member and SSG Freedoms sister, currently
    deployed to Denver airport, will meet him when he
    returns

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Redeployment Task In-Theater Medical
Out-Processing
  • Task In-Theater Medical Out-processing
  • When Within 5 days prior to redeployment
  • Who CFLCC (Coalition Forces Land Component
    Command) medical assets
  • Credentialed provider
  • Tools
  • DD Forms 2766, 2795, 2796
  • Paper, fillable PDF, and electronic
  • Medical threat debrief - on CHPPM and
    PDHealth.mil websites
  • Med threat info sheet also on both websites
  • Medical prophylaxis malaria, others
  • Aids Consult helpline, patient education
    materials, email CHPPM POC in-theater

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Redeployment Soldiers, Federal PersonnelTask
In-Theater Medical Out-Processing
Medical Debrief Soldier receives medical threat debrief (CHPPM website)
Medical Threat Information Sheet Soldier receives two medical threat tri-folds (one medical, one family CHPPM website)
Soldier completes DD 2796 Can fill in front sections independently or with assistance from medical screener
Medical exam Face-to-face encounter with provider review, complete 2796 document exposures, physical mental concerns
Terminal Prophylaxis Determine/provide malaria and other prophylaxis needs
Provider referrals Determine and initiate referral to PCM for PDH-CPG based care
Document visit and sign 2796 ICD-9 Code V70.5_6, and other codes as needed provider signs completed 2796
Integrate 2796 into DD 2766 Deployable health record, 2766, should be annotated, integrate 2796 with previously completed 2795
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DD Form 2796 Post-Deployment Health Assessment -
Pages 1 2
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DD Form 2796 Post-Deployment Health Assessment
Pages 3 4
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Mental Health Items (DD2796)
  • Additional clarification of history directed by
    the screening provider's clinical suspicion is
    mandated for anyone who reports
  • A desire for assistance (item 10)
  • ANY concerns about self-harm (item 11c)
  • A LOT to any of the other depression screening
    items (item 11)
  • Two or more of the acute stress
    disorder/post-traumatic stress disorder screening
    items (item 12) OR
  • ANY concerns over loss of control (item 13b)

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Redeployment Soldiers, Federal PersonnelTask
In-Theater Medical Out-Processing
Medical Debrief Soldier receives medical threat debrief (CHPPM website)
Medical Threat Information Sheet Soldier receives two medical threat tri-folds (one medical, one family CHPPM website)
Soldier completes DD 2796 Can fill in front sections independently or with assistance from medical screener
Medical exam Face-to-face encounter with provider review, complete 2796 document exposures, physical mental concerns
Terminal Prophylaxis Determine/provide malaria and other prophylaxis needs
Provider referrals Determine and initiate referral to PCM for PDH-CPG based care
Document visit and sign DD2796 ICD-9 Code V70.5_6, and other codes as needed provider signs completed DD2796
Integrate DD2796 into DD 2766 Deployable health record, DD2766, should be annotated, integrate DD2796 with previously completed DD2795
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Redeployment Soldiers and Civil ServiceTask
Home Station/Demob Medical Processing16 May, Day
of Return
  • Task Home Station Medical Processing
  • When Within 5 days post redeployment
  • Who Credentialed provider Homer Station, MD
  • Assistance LPN Grace, contract screener, or SSG
    Whiskey
  • Tools
  • DD Forms 2766, 2796, 2795, SF600 with stamp,
    Medical Record, CHCS pick list
  • Medical threat debriefing - on CHPPM and
    PDHealth.mil websites
  • Medical threat information sheet - also on
    website
  • Medical prophylaxis malaria, others
  • Aids Toll-free help line numbers
  • Medical consult helpline 1-866-559-1627
  • Patient education helpline - especially helpful
    for reserve component personnel 1-800-796-9699

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Redeployment Soldiers and Civil ServiceTask
Home Station/Demob Medical Processing
Medical Debrief Ensure soldier has received medical threat debrief (CHPPM website)
Medical Threat Information Sheet Ensure soldier received two medical threat tri-folds (one medical, one family CHPPM website)
Review medical documentation Review documents with soldier has the DD2796 been completed and signed and inserted into DD2766?
Medical exam with provider, as needed If DD2796 is not completed or present Face-to-face encounter review/complete DD2796 document exposures, physical mental concerns code V70.5_6 () sign
Terminal Prophylaxis If not completed in theater Determine/provide malaria and other prophylaxis needs
Blood and TB Blood sample taken for HIV and Serum Repository TB/PPD immediately and again 90 days post-deployment
Provider referrals For all Determine need from documentation or exam ensure referral to PCM for PDH-CPG based care
Integrate DD2796 and DD2766 Integrate all deployment health documents into permanent medical record mail copy or send electronic DD2796 to AMSA
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Redeployment Reserve ComponentTask Additional
RC Medical Processing
Medical benefit/ entitlement benefit Ensure each RC soldier receives medical benefit/entitlement brief on www.pdhealth.mil/reservist/personnel and (http//www.defenselink.mil/ra/documents/family/demob.ppt)
Soldier completes DD Form 2697 All personnel released from AD (REFRAD) must complete MEDICAL ASSESSMENT, DD2697 (on pdhealth.mil website)
Health Record Review Provider reviews DD 2697 and other documentation to identify health problems that require additional follow-up
Soldier must actively decline medical exam Physical exam is part of DD2697 default is do the exam unless soldier declines
Complete routine demob medical processing Complete medical processing as in AD scenario refer to PCM as needed for PDH-CPG-based follow-up
LOD required Determine if Line of Duty (LOD) determination is required initiate LOD as needed
ADME requirement Determine if Active Duty Medical Extension is required to clear current health concerns.
Complete documentation Integrate all deployment health documents into permanent medical record mail copy or send electronic DD2796 to AMSA
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RedeploymentNGO and Civilian, Non-Government
Personnel
  • Contractors non-federal workers
  • Covered under health insurance of their
    contracting company occupational medicine and PM
    only if part of contract
  • Private and network health care providers can get
    information about guideline-based care through
    help-line and website
  • Also Tricare network and VA providers can access
    info
  • NGO Personnel Policies
  • Red Cross, USO, and other non-government
    personnel are not included in the demobilization,
    medical processing, or follow-up medical care
  • Can be exceptions with Secretary of the Army
    designee status
  • Embedded journalists
  • A new population
  • Not a military health care beneficiary group

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Redeployment Task Primary Care PDH-CPG DD 2796
Follow-up
  • 3. Task Primary Care PDH-CPG DD 2796 Follow-up
  • When Should follow ASAP from ID during demob
    process
  • Recommend NLT 7 days of reintegration, may need
    immediate
  • Sick call vs. appointment process for large
    groups
  • Who
  • Receptionist - Harmony
  • Medical screener/LPN SSG Whiskey or LPN Grace
  • Primary Care Manager Dr. Station
  • Tools
  • SF600 with screening question or stamp
  • Toolbox PDH Clinic Visit Desk Reference Card
  • DD Form 2844
  • Aids
  • Web site and algorithms ENVITE mnemonic
  • Prior training and role play of situations

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Toolbox Reference Cards PDH Clinic Visit
  • Provides guidance for
  • training screeners about the
  • deployment-related question
  • How to ask the question
  • Emphasizes that deployment
  • is not necessary to have PDH
  • concerns
  • How to respond to patients
  • questions
  • Examples of deployments and
  • deployment-related concerns or
  • conditions

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Optional DD Form 2844 - Post Deployment Medical
Assessment Form and Primer
  • Optional form for documenting
  • post-deployment medical evaluation
  • Form available and can be
  • be completed on line at
  • www.PDHealth.mil

Toolbox DD 2844 Primer
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Redeployment Task Primary Care PDH-CPG DD
2796 Follow-up (cont.)
  • 3. Process Primary Care PDH-CPG DD 2796
    Follow-up
  • SSG Freedom reports, as instructed, to PC on 17
    May
  • Persistent cough, congestion fears SARS (Severe
    Acute Respiratory Syndrome)
  • SSG Guard reports to PC on same day, with same
    sx, concerned because of work at the airport
  • Greeted courteously by Receptionist, Harmony
  • Vignette

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Redeployment Task Primary Care PDH-CPG DD 2796
Follow-up (cont.)
  • 3. Process Primary Care PDH-CPG DD 2796
    Follow-up
  • Medical screener/LPN SSG Whiskey or LPN Grace
  • Asks deployment-related vital sign
  • "Is your problem today related to a deployment?"
  • Marks yes on stamped SF600 (or pre-printed SF
    600 at TMC)
  • Alerts provider to yes response
  • Original DD Form 2796 in permanent medical record
  • Color coded forms or folders have been used
  • DD Form 2844 on follow-up appointment

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Redeployment Task Primary Care PDH-CPG DD 2796
Follow-up (cont.)
  • 3. Process Primary Care PDH-CPG DD 2796
    Follow-up
  • Provider Dr. Station
  • Acknowledges that visit is deployment-related
  • Reinforces follow-up from DD2796 instructions
  • Express appreciation for service compassion for
    concerns
  • Stepped-risk communication model (see guideline)
  • ENVITE mnemonic for risk communication
  • Info on deployment risks (see PDHealth.mil web
    site)
  • Risk communication takes place throughout
    encounter, not just at end
  • Reviews DD2796 (and DD2844 on follow-up visit)
  • Evaluates chief complaint identifies
    established diagnosis
  • Viral respiratory infection (not consistent with
    SARS)

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Stepped Risk CommunicationRecognized Disease
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Redeployment Task Primary Care PDH-CPG DD 2796
Follow-up (cont.)
  • 3. Process Primary Care PDH-CPG DD 2796
    Follow-up
  • Provider Dr. Station
  • Documents deployment-related visit primary code
    V70.5_6
  • Documents disease-specific diagnosis as secondary
    code
  • Establishes follow-up appointment both IAW
    disease specific guideline and for PDH concern
    (30 minute PDH appt where DD Form 2844 is used)
  • Prior to follow-up Researches if SARS was a
    potential exposure in area of operations or
    during return trip for discussion in follow-up

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Redeployment Task Primary Care PDH-CPG DD 2796
Follow-up (cont.)
  • 3. Process Primary Care PDH-CPG DD 2796
    Follow-up
  • Case Management Function
  • Adds PDH-CPG Patient to the tracking database
  • Ensures follow-up made
  • Provides additional patient educational
    materials, as requested by patient/provider
  • Quality controls coding

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Redeployment Task Primary Care PDH-CPG
Definitive Diagnosis
  • 3. Definitive Dx Family Member 15 Jun 03
  • Patience Freedom brings 8 y/o son, Butch, to PC
  • Describes conflict with dad since return from
    Iraq son getting into fights at school
  • Ask screening question military vital sign
  • Document screening response and alert provider
  • Provider recognizes deployment-related nature
  • Provide effective risk communication
  • Refer to Behavioral Health provider
  • Document deployment V-code and family problem
    V-code
  • Follow-up, track, and manage case

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Redeployment Task Primary Care PDH-CPG
Definitive Diagnosis (cont.)
  • 3. Definitive Dx Family Member
  • Key points to remember
  • Deployment-related problems not limited to
    service members or adults
  • Can be spouse, child, or retiree
  • Family affected by stress and also can be exposed
    to contaminants, bacteria, etc. brought back by
    soldier
  • Process remains the same

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Redeployment Task Primary Care PDH-CPG
Definitive Diagnosis (cont.)
  • 3. Definitive Dx Key Points
  • Ensure risk communication in clinic contacts
  • Ask screening question military vital sign
  • Document screening response and alert provider
  • Provider recognizes deployment-related nature
  • Triage Identify definitive diagnosis
  • Provide effective risk communication
  • Document deployment V-code and disease diagnosis
    code
  • Follow-up, track, and manage case

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ICD-9 Coding for Identifiable Disease
  • V70.5_ 6
  • Deployment-related visit
  • plus
  • Usual Disease Code

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Asymptomatic Patient with Health Concerns
  • Expresses a health concern, but does not exhibit
    or describe any discernable illness or injury
  • Concerns related to
  • Illness
  • Vaccine or anticipated vaccine or meds
  • Exposure or anticipated exposure
  • An experience
  • News media coverage, internet, etc.
  • Can be service member or family member
  • Legitimate health care visit

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Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment Asymptomatic Concerned (cont.)
  • Post-deployment Presentation 30 Jun 03
  • SSG Freedom presents to clinic
  • Describes concerns about DU, read article in
    paper
  • Saw armored vehicle blown-up, no wounds
  • Note on wounded processes
  • Tools
  • SF600 screening question
  • Toolbox Desk Reference Cards
  • DD Form 2844 on follow-up visit
  • Aids
  • Fact Sheets
  • PDHealth.mil web site and DHCC Deployment Health
    Daily News
  • Provider help-line 1-866-559-1627

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Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment Asymptomatic Concerned (cont.)
  • Post-deployment, Asymptomatic Concerned
  • Process
  • SSG Whiskey/LPN Grace asks deployment-related
    screening question
  • Records yes, alerts provider to
    deployment-related visit
  • Provider expresses recognition to patient that
    the visit is deployment-related and reinforce
    decision to make a health care visit to discuss
  • Employs risk communication through stepped-care
    algorithm and ENVITE reminder

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Stepped Risk CommunicationAsymptomatic Concerned
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Worldwide Web Support forPost-Deployment Health
Carewww.PDHealth.mil
  • Information on all
  • deployments and
  • deployment cycle support
  • Specific diseases and
  • emerging health concerns
  • Web-navigable version of
  • the PDH-CPG
  • Online clinical tools
  • News and information library
  • Provider education and
  • training
  • Patient education

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Deployment Health News
  • Email newsletter each
  • business day
  • Deployment-related news
  • articles
  • To subscribe, sign up at
  • www.pdhealth.mil/
  • nl_signup.asp

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Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment Asymptomatic Concerned (cont.)
  • Summary Asymptomatic Concerned Key Points
  • Ensure risk communication in clinic contacts
  • Ask screening question military vital sign
  • Document screening response and alert provider
  • Provider recognizes deployment-related nature
  • Triage Identify Asymptomatic Concerned
  • Provide effective risk communication
  • Document patient education
  • Code V70.5_6 and V65.5
  • Research and 30 minute follow-up
  • Follow-up, track, and manage case

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Medically Unexplained Symptoms (MUS)
  • Physical symptoms that provoke care-seeking, but
    have no clinically determined pathogenesis after
    an appropriately thorough diagnostic evaluation.
  • V70.5_ 6 plus ICD-9-CM MUS Code 799.89
  • Note ICD-9-CM Guidelines 2005 changed MUS code
    from 799.8 to 799.89.

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Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment MUS
  • Post-deployment Presentation 15 Sept 03
  • SSG Freedom presents to clinic
  • Describes fatigue, headache, cant sleep,
    episodic rash
  • Symptoms on and off since return from Iraq
  • Tools
  • SF600 screening question
  • Toolbox Desk Reference Cards
  • DD Form 2844 on initial follow-up visit
  • Assessment and outcome instruments
  • SF36, PHQ, PDCAT
  • Aids
  • PDHealth.mil web site
  • Provider help-line 1-866-559-1627

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Assessment and Outcome Tools
SF-36v2
  • SF-36v2 - Health Survey
  • Short measure of health-
  • related quality of life
  • PHQ - Patient Health
  • Questionnaire
  • Screens and monitors status
  • of common health conditions
  • PDCAT - Post Deployment
  • Health Clinical Assessment Tool
  • Measures certain aspects of
  • physical and mental health
  • Useful in following post-
  • deployment health conditions

PHQ
PDCAT
Forms and primers on www.PDHealth.mil
81
Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment MUS (cont.)
  • Process Medically Unexplained Symptoms
  • Ask screening question document alert
    provider recognize deployment-related
  • Use DD Form 2844 to capture more thorough history
  • Conduct clinical assessment
  • Administer functional assessment and outcome
    measure
  • Use effective risk communication and patient
    education materials

82
Stepped Risk CommunicationMedically Unexplained
Symptoms
Concerned, Unexplained Symptoms
  • Symptom-based patient education
  • Consult specialty care
  • Deployment Health Clinical Center consult
  • Consider Specialized Care Program for chronic
  • symptoms

Concerned, Asymptomatic
Concerned, Recognized Disease
  • Education
  • Web and Print
  • 30 minute
  • Follow-up appt
  • Disease-centered
  • patient education
  • Disease prognosis
  • Disease treatment
  • options

Unconcerned, Recently Deployed
Routine rapport trust-building
83
VA/DoD Medically UnexplainedSymptoms (MUS)
Clinical Practice Guideline
84
Medically Unexplained SymptomsPatient Education
Brochures
Available from the DHCC web site www.PDHealth.mil
Available from the MEDCOM web site
www.qmo.amedd.army.mil
85
Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment MUS (cont.)
  • Process Medically Unexplained Symptoms
  • Refer to MUS-specific Clinical Practice Guideline
  • Also at www.pdhealth.mil, Supporting Guidelines
  • Additional guidelines Depression, PTSD
  • Consider specialty care and second opinions
  • Always follow-up, even when referral to specialty
    care case management
  • Case Management
  • 30-minute appt for patient education and RC
  • Tele-consult DHCC
  • For unresolved concerns Consider referral to
    DHCC Specialized Care Program for rehabilitative
    care
  • Dont forget to code V70.5_6 Deployment-related
    visit plus 799.89 (Ill-defined condition)

86
DHCC Clinical CareSpecialized Care Programs(SCP
Tracks I and II)
  • Intensive, 3-week, multidisciplinary,
    rehabilitative
  • program for patients with deployment-related
    chronic illness
  • or Medically Unexplained Symptoms or
    post-operational stress
  • Available to all military members and family
    members who
  • continue to have problems after going through
    PDH-CPG based
  • care at local MTF and meet admission criteria
    (e.g., ambulatory,
  • capable of some exercise) (Track II for
    military members only)
  • Behavioral and self-care strategies and
    treatments include
  • Physical conditioning
  • Patient education
  • Counseling
  • Nutritional counseling
  • Occupational therapy
  • Relaxation training
  • Cognitive-behavioral therapy
  • Exposure therapy

87
Deployment Health Clinical Center Resource Center
  • DHCC Helpline for Clinicians/Providers
    (Administrative and clinical consultation
    - Mon-Fri 0730-1630)
  • US Toll Free  1-866-559-1627
  • Local No. 202-356-0907 (DSN 642)
  • Outside US DSN 312-642-0907
  • DoD Helpline for Veterans and Family Members
    (Patient information, referral, advocacy -
    Mon-Fri 0730-1630)
  • US Toll Free 1-800-796-9699
  • Local No.  202-782-3577 (DSN 662)
  • From Europe Toll Free  00800-8666-8666
  • Outside US DSN  312-662-3577
  • Email Questions
  • pdhealth_at_amedd.army.mil

88
Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment MUS (cont.)
  • Summary Medically Unexplained Symptoms
  • Ask screening question military vital sign
  • Document screening response and alert provider
  • Use DD Form 2844
  • Provider recognizes deployment-related nature
  • Evaluate clinically refer to MUS CPG
  • Use assessment and outcome tools on pdhealth.mil
  • e.g., SF36, PHQ, PDCAT
  • Provide effective risk communication
  • Code V70.5_6 and 799.89
  • Research, 30 minute follow-up
  • Consult specialty care DHCC phone consult
    DHCC rehabilitative care for chronic MUS
  • Follow-up, track, and manage case

89
Pre-Deployment Phase of Cycle Task Primary
Care PDH-CPG Evaluation and Treatment
  • Pre-deployment 1 Nov 03
  • SSG Reserve is on reserve drill at Ft Carson
    scheduled to be deployed again in
    60 days
  • Reports to Primary Care describes flashbacks of
    last combat, inability to sleep, intrusive
    thoughts of seeing friend killed in tank
    explosion, easily startled, drinking a lot lately
  • Tools
  • All previous PDH-CPG tools
  • PTSD screening scale (on web site)
  • Risk communication very important at this point
  • Process Follow Definitive Diagnosis Algorithm
    (A3)
  • Refer to VHA nearer to his home for treatment
  • Key
  • MUS is not the same as MH (mental health) concern
  • PDH-CPG applies throughout the Deployment Cycle
  • VA offers Reserve and Guard care 2 years
    post-deployment
  • Vet Centers available for family counseling

90
Post Traumatic Stress DisorderChecklists, Primer
and CPG
  • Assesses trauma-related distress
  • Self-administered
  • 3 Versions
  • Civilian Version (PCL-C)
  • Military Version (PCL-M)
  • Stress Specific Version (PCL-S)
  • Available on www.PDHealth.mil

PCL-M
PTSD CPG
PCL Primer
91
Deployment Health AssessmentForms and Primers
DD Form 2795
  • DD Form 2795, Pre-Deployment
  • Health Assessment
  • Reviewed by a credentialed provider
  • for positive responses
  • DD Form 2796, Post-Deployment
  • Health Assessment
  • Face to face assessment by trained health
  • care provider (physician, physician
  • assistant, nurse practitioner, independent
  • duty corpsman/medical technician)
  • Available on www.PDHealth.mil

DD 2795 Primer
DD Form 2796
DD 2796 Primer
92
PDH-CPG Training Briefs
  • Produced by DHCC
  • 7 video modules
  • from 7-12 minutes
  • Developed for
  • medical providers
  • and support staff
  • Posted on DHCC
  • web site
  • www.PDHealth.mil

Table of Contents
  • Introduction
  • Primary Care Screening
  • Primary Care Evaluation
  • Management Follow-up
  • Health Risk Communication
  • Coding and Documentation
  • PDHA

93
Deployment Health ClinicalTraining Series
  • Produced by DHCC
  • 11 modules from
  • 17-47 minutes
  • Video, script, slides
  • Developed for medical
  • providers and support
  • staff
  • Posted on DHCC web site
  • www.PDHealth.mil

Table of Contents
  • PDH-CPG
  • Introduction/Overview
  • Screening/Evaluation
  • Management/Follow-up
  • Risk Communication
  • Coding/Documentation
  • PDHA Process
  • Emerging Health Concerns
  • Suicide
  • Malaria
  • Depleted Uranium
  • Leishmaniasis
  • Vaccine Safety

94
Unlesswars are fought solely by machines, the
human cost of warfare will remain high. The
troops mustbe given a commitment for all
necessary care for war-related illness.
Straus SE Lancet 1999 353162-3
95
Questions, Information,Assistance
DoD Deployment Health Clinical Center
Walter Reed Army Medical Center Building 2,
Room 3G04 6900 Georgia Ave, NW Washington, DC
20307-5001 E-mail
pdhealth_at_na.amedd.army.mil Website
www.PDHealth.mil
202-782-6563 DSN662
Provider Helpline 1-866-559-1627
Patient Helpline 1-800-796-9699
View by Category
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Implementing the PDH-CPG Across the Deployment Cycle Post OEF/OIF May 2003 (Updated April 2005)

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Title: Implementing the PDH-CPG Across the Deployment Cycle Post OEF/OIF May 2003 (Updated April 2005)


1
Implementing the PDH-CPGAcross the Deployment
CyclePost OEF/OIFMay 2003 (Updated April 2005)
  • pdhealth_at_amedd.army.mil
  • Provider Consult HelpLine 1-866-559-1627
  • Patient Call Center HelpLine 1-800-796-9699

2
Training Agenda
Introduction and Guideline Overview LTC Charles Engel
Basics of Risk Communication Tim OLeary
Post-Deployment Health Assessment 2796 Enhanced Process COL Jeff Gunzenhauser
PDH CPG Application Lt Col Adkins, LTC Engel, Mr. OLeary
Summary and Questions
3
Why Focus On Post-Deployment Health
Care?(Isnt it just routine health care in a
slightly different uniform?)
4
because our workplace may be hazardous to health
History Made Overly Simple Before VietnamLife
Limb After VietnamPost-Traumatic Stress
Disorder After Gulf WarToxic Exposure
ConcernsMedically Unexplained Symptoms
5
Gulf War Syndrome
  • 17 of UK Gulf War Veterans believe they have
    Gulf War Syndrome

6
(No Transcript)
7
(No Transcript)
8
Recent Unexplained Syndromes Involving the
Military, War, Deployment, or Terror
  • Dutch peacekeepers in Lebanon (1980s)
  • Jungle Disease (Dutch peacekeepers in Cambodia)
  • Gulf War Syndrome
  • Afghanistan Syndrome (Russia, 1990s)
  • Chechnya Syndrome (Russia, 1990s)
  • Illnesses after 1992 El Al Airliner crash in
    Amsterdam
  • Illnesses after anthrax vaccination (1990s)
  • Dutch peacekeepers in Bosnia (1995-6)
  • Canadian peacekeepers in Croatia (late 1990s)
  • Balkan War Syndrome

9
(No Transcript)
10
Unexplained Physical SymptomsMedicines Dirty
Little Secret
  • Specialty Clinical SyndromeOrthopedics Low Back
    Pain Patellofemoral Syndrome
  • Gynecology Chronic Pelvic Pain Premenstrual
    Syndrome
  • ENT Idiopathic Tinnitus
  • Neurology Idiopathic Dizziness Chronic Headache
  • Urology Chronic Prostatitis Interstitial
    Cystitis Urethral Syndrome
  • Anesthesiology Chronic Pain Syndromes
  • Cardiology Atypical Chest Pain Idiopathic
    Syncope Mitral Valve Prolapse
  • Pulmonary Hyperventilation Syndrome
  • Endocrinology Hypoglycemia
  • Specialty Clinical Syndrome Dentistry
    Temporomandibular Disorder
  • Rheumatology Fibromyalgia Myofascial
    Syndrome Silicosis
  • Internal Medicine Chronic Fatigue Syndrome
  • Infect Disease Chronic Lyme Chronic Epstein-Barr
    Virus Chronic Brucellosis Chronic Candidiasis
  • Gastroenterology Irritable Bowel Syndrome
    Gastroesophageal Reflux
  • Physical Medicine Mild Closed Head Injury
  • Occupational Multiple Chemical SensitivityMedicin
    e Sick Building Syndrome
  • Military Medicine Gulf War Syndrome
  • Psychiatry Somatoform Disorders

11
(No Transcript)
12
Institute of Medicine
  • Strategy 5 Implement strategies to address
    medically unexplained physical symptoms in
    populations that have been deployed.

WA, DC, National Academy Press 2000
13
A DoD Center of Excellence
  • Deployment Health Clinical Center

Mission Improve post-deployment health care
for DoD beneficiaries
Located at Walter Reed Army Medical Center
14
How Can We Do Better?
15
(No Transcript)
16
DoD-VA CLINICAL PRACTICE GUIDELINE
ONPOST-DEPLOYMENT HEALTH EVALUATION MANAGEMENT
17
Post-Deployment Health Clinical Practice
Guideline (PDH-CPG)
  • DoD/VA Post-Deployment Health Evaluation and
  • Management Clinical Practice Guideline
    (PDH-CPG)
  • Evidence-based guideline for the evaluation and
    management of patients with deployment-related
    health concerns/conditions in the primary care
    setting
  • Completed by an expert multi-disciplinary,
    multi-agency panel in 2001
  • Initiated with a worldwide satellite broadcast
    January 2002 and distribution of a Tool Kit to
    all MTFs
  • Replaced Comprehensive Clinical Evaluation
    Program (CCEP)
  • No change since 2002 except modified coding
    guidance

18
PDH-CPG Use Mandated by Health Affairs April
2002
All DoD military treatment facilities should now
be using the Post-Deployment Health Clinical
Practice Guideline the military unique vital
sign question Is the reason for your visit today
related to a deployment? should be asked of
every patientproviders will review and employ,
as needed, this guideline during their
evaluations
19
PDH-CPG Components
Primary Care Clinic Visit Military Vital Sign
Screening
Post-Deployment Health Assessment DD Form 2796
PDH-CPG
Symptomatic With No Diagnosis Medically
Unexplained Symptoms Algorithm A2
Symptomatic With Diagnosis Algorithm A3
Asymptomatic Concerned Algorithm A1
20
Overview of Guideline Features
  • Military-unique vital sign
  • Stepped care framework
  • Risk communication guidance
  • Web-based clinician support
  • Longitudinal care emphasis
  • Data automation features
  • Metrics outcomes monitoring
  • Supporting Center of Excellence

21
What Is the Military Unique Vital Sign?
  • All persons should be asked Is your health
    concern today related to a deployment? at every
    primary care visit except wellness visits (e.g.
    periodic exams and preventive care)
  • Patient rather than provider determination
  • Percentage of positive responses
  • lt1 during 2001 testing (Bragg, Lejeune, McGuire)
  • 2.8 AD vs 0.2 FM in NQMP study published Dec 04
  • 5-8 in current data reviews

22
Stepped Risk Communication
23
Local Challenges
  • Identifying a champion clinical administrative
  • Local gap analysis
  • Implementing the question?
  • Adhering to visit coding?
  • Assessing follow-up metrics?
  • Local Utilization Management/Informatics support?
  • Making provider patient information available
    from the toolkit?
  • Obtaining risk communication training?
  • Receiving DHCC News? Medical Early Bird for
    those who want to know what patients may be
    reading

24
Risk Communication Its Relevance for Clinicians
25
What is Risk Communication?
  • An interactive process of exchange of information
    and opinion among individuals, groups, and
    institutions. It involves multiple messages
    about the nature of risk and other messages, not
    strictly about risk, that express concern,
    opinions, or reactions to risk messages or to
    legal and institutions arrangements for risk
    managers.
  • National Research Council, Committee on Risk
    Perception and Communication

26
What is Risk Communication?(cont.)
  • Building and maintaining relationships based on
    the effective exchange of technical and/or
    scientific information between concerned
    stakeholders about an actual or perceived risk
  • Risk Communication Team, U.S. Army Center for
    Health Promotion and Preventive Medicine

27
What is Risk Communication?(cont.)
  • A science-based approach for communicating
    effectively in
  • High concern
  • Low trust
  • Sensitive or
  • Controversial situations
  • Vincent Covello, Center for Risk Communication

28
Gaining Trust and Credibility
  • Difficult to gain and easy to lose
  • Most important factors are
  • Empathy
  • Caring
  • Personal Commitment
  • Honesty
  • Openness
  • Expertise

29
Risk Communication History
  • Risk communication dates back to 1980s
  • Interact with communities or groups
  • Concern about health, safety, or environmental
    dangers
  • Perception of peril to themselves especially to
    their children

30
Seven Rules of Risk Communication
  • Rule 1. Accept and involve the recipient of
    information as a legitimate partner
  • Rule 2. Plan carefully and evaluate performance
  • Rule 3. Listen to your audience
  • Rule 4. Be honest, frank, and open

31
Seven Rules of Risk Communication (cont.)
  • Rule 5. Coordinate and collaborate with other
    credible sources
  • Rule 6. Plan for Media influence
  • Rule 7. Speak clearly and with compassion

32
Narrowing Risk Communication
  • Until recently, risk communication was used for
    groups and communities
  • In a clinical setting, risk communication is used
    with small groups (e.g., family) or individuals
  • Building trust and credibility remains crucial
  • Fosters a good environment for communicating
    sensitive health risk information
  • Listening is half of communication

33
Stepped Risk Communication Strategy
Concerned, Unexplained Symptoms
  • Key element of PDH-CPG
  • Routine primary care assessment
  • routine trust rapport building
  • Ascend risk communication
  • stairs as outlined above

34
Clinical Health Guidelines
  • Risk communication is a central part of the
    guideline
  • Routine primary care assessment routine trust
    rapport building
  • Ascend risk communication stairs for
  • Unconcerned patient, but recently deployed
  • Concerned patient with recognized disease
  • Concerned patient who is asymptomatic
  • Concerned patient with chronic unexplained
    symptoms

35
Why Use Risk Communication?
  • Allows transmission of relevant accurate health
    information
  • Increases patient provider focus on relevant
    health risks
  • Reduces unnecessary patient distress

36
Benefits of Risk Communication
  • Improves patient
  • Acceptance and adherence to medical advice
  • Satisfaction with care
  • Confidence in provider their relationship
  • Trust in the health care system
  • Functioning health behaviors
  • Chances of returning to life roles
  • Improves provider satisfaction with the process
    of delivering care

37
What Risks Concern Patients?
  • Risk of serious illness
  • Risk of various outcomes (e.g., cure, death,
    disability)
  • Risks of medical tests
  • Risks of medical treatments
  • Risk of workplace or environmental exposures

38
Clinical Risk CommunicationE N V I T E
  • E-mpathy Listen actively. Confirm what you
    hear. Express concern. Convey genuine desire to
    assist.
  • N-on confrontational Subordinate the need to be
    right to the obligation to relieve suffering.
    Dont engage in arguing with patient.
  • V-alidate Validate the patients decision to
    seek care.
  • I-nform Offer data that addresses patients
    specific concerns presented in an understandable
    way.
  • T-ake Action Describe options. Appropriate
    tests/labs. Schedule a follow-up. Research
    concerns. Consider consultation or second
    opinion, as needed.
  • E-nlist Cooperation Negotiate an action plan
    with the patient rather than imposing one on him
    or her.

39
Who Needs Risk Communication Expertise?
  • Physician
  • Nurse
  • Desk Clerk/Receptionist

40
Risk CommunicationSummary
  • Clinical risk communication involves low
    trust-high concern situations
  • Trust and credibility are the heart of
    communicating health information to patients
  • Value your patients views and beliefs

41
Post-Deployment Health Clinical Practice
GuidelineTools Application
42
Enhanced PDHA Process www.PDHealth.mil
  • Guidance for Completing
  • DD Form 2796
  • PDHA Policies Directives
  • Deployment Exposures
  • Information
  • Redeployment Briefing
  • PDHA Training Videos

Toolbox DD2796 Primer
43
PDH-CPG Web-Based Toolswww.PDHealth.mil
  • PDH Guidelines
  • Overview
  • Guideline
  • Algorithms
  • Implementation
  • Desk Reference Toolbox
  • Tool Kit (Updated by Toolbox)
  • CCEP Transition
  • Broadcast, 30 Jan 2002
  • Supporting Guidelines
  • Clinicians Helpline
  • 1-866-559-1627

Home Page
PDH Guidelines
44
PDH-CPG Desk Reference Toolbox
  • Desktop-sized Laminated Box
  • Desk Reference Cards
  • Compact Discs
  • Interactive PDH-CPG
  • MEDCOM CD of Other CPGs
  • 2 PDH-CPG Training CDs
  • Sample Clinician and Patient
  • Brochure
  • Vaccine Healthcare Centers
  • Immunization Tool Kit

Contents on www.PDHealth.mil
45
Deployment Cycle Support (DCS)Scenario - 12 May
03
  • Personnel and situation
  • SSG Ira Freedom
  • 29 y/o male stationed at Ft Carson
  • Married, wife (Patience), 8 y/o son, 4 y/o
    daughter
  • In SWA for 90 days
  • In Kuwait and Iraq as part of OEF and OIF
  • Saw 2 weeks in combat, including heavy resistance
    in Baghdad urban warfare
  • No significant medical history prior to
    deployment
  • Anticipates redeployment on 15 May

46
Deployment Cycle Support (DCS)Scenario - 12 May
03 (cont.)
  • SSG Freedoms friends in Iraq
  • Formed bond due to similar history
  • SSG Reserve, a mobilized reservist
  • Mr. Seville, a deployed federal civil service
    employee
  • Ms. Cross, a Red Cross Volunteer
  • Ed Itor, an embedded journalist
  • All going back on 15 May
  • SSG Natalie Guard, a mobilized National Guard
    member and SSG Freedoms sister, currently
    deployed to Denver airport, will meet him when he
    returns

47
Redeployment Task In-Theater Medical
Out-Processing
  • Task In-Theater Medical Out-processing
  • When Within 5 days prior to redeployment
  • Who CFLCC (Coalition Forces Land Component
    Command) medical assets
  • Credentialed provider
  • Tools
  • DD Forms 2766, 2795, 2796
  • Paper, fillable PDF, and electronic
  • Medical threat debrief - on CHPPM and
    PDHealth.mil websites
  • Med threat info sheet also on both websites
  • Medical prophylaxis malaria, others
  • Aids Consult helpline, patient education
    materials, email CHPPM POC in-theater

48
Redeployment Soldiers, Federal PersonnelTask
In-Theater Medical Out-Processing
Medical Debrief Soldier receives medical threat debrief (CHPPM website)
Medical Threat Information Sheet Soldier receives two medical threat tri-folds (one medical, one family CHPPM website)
Soldier completes DD 2796 Can fill in front sections independently or with assistance from medical screener
Medical exam Face-to-face encounter with provider review, complete 2796 document exposures, physical mental concerns
Terminal Prophylaxis Determine/provide malaria and other prophylaxis needs
Provider referrals Determine and initiate referral to PCM for PDH-CPG based care
Document visit and sign 2796 ICD-9 Code V70.5_6, and other codes as needed provider signs completed 2796
Integrate 2796 into DD 2766 Deployable health record, 2766, should be annotated, integrate 2796 with previously completed 2795
49
DD Form 2796 Post-Deployment Health Assessment -
Pages 1 2
50
DD Form 2796 Post-Deployment Health Assessment
Pages 3 4
51
Mental Health Items (DD2796)
  • Additional clarification of history directed by
    the screening provider's clinical suspicion is
    mandated for anyone who reports
  • A desire for assistance (item 10)
  • ANY concerns about self-harm (item 11c)
  • A LOT to any of the other depression screening
    items (item 11)
  • Two or more of the acute stress
    disorder/post-traumatic stress disorder screening
    items (item 12) OR
  • ANY concerns over loss of control (item 13b)

52
Redeployment Soldiers, Federal PersonnelTask
In-Theater Medical Out-Processing
Medical Debrief Soldier receives medical threat debrief (CHPPM website)
Medical Threat Information Sheet Soldier receives two medical threat tri-folds (one medical, one family CHPPM website)
Soldier completes DD 2796 Can fill in front sections independently or with assistance from medical screener
Medical exam Face-to-face encounter with provider review, complete 2796 document exposures, physical mental concerns
Terminal Prophylaxis Determine/provide malaria and other prophylaxis needs
Provider referrals Determine and initiate referral to PCM for PDH-CPG based care
Document visit and sign DD2796 ICD-9 Code V70.5_6, and other codes as needed provider signs completed DD2796
Integrate DD2796 into DD 2766 Deployable health record, DD2766, should be annotated, integrate DD2796 with previously completed DD2795
53
Redeployment Soldiers and Civil ServiceTask
Home Station/Demob Medical Processing16 May, Day
of Return
  • Task Home Station Medical Processing
  • When Within 5 days post redeployment
  • Who Credentialed provider Homer Station, MD
  • Assistance LPN Grace, contract screener, or SSG
    Whiskey
  • Tools
  • DD Forms 2766, 2796, 2795, SF600 with stamp,
    Medical Record, CHCS pick list
  • Medical threat debriefing - on CHPPM and
    PDHealth.mil websites
  • Medical threat information sheet - also on
    website
  • Medical prophylaxis malaria, others
  • Aids Toll-free help line numbers
  • Medical consult helpline 1-866-559-1627
  • Patient education helpline - especially helpful
    for reserve component personnel 1-800-796-9699

54
Redeployment Soldiers and Civil ServiceTask
Home Station/Demob Medical Processing
Medical Debrief Ensure soldier has received medical threat debrief (CHPPM website)
Medical Threat Information Sheet Ensure soldier received two medical threat tri-folds (one medical, one family CHPPM website)
Review medical documentation Review documents with soldier has the DD2796 been completed and signed and inserted into DD2766?
Medical exam with provider, as needed If DD2796 is not completed or present Face-to-face encounter review/complete DD2796 document exposures, physical mental concerns code V70.5_6 () sign
Terminal Prophylaxis If not completed in theater Determine/provide malaria and other prophylaxis needs
Blood and TB Blood sample taken for HIV and Serum Repository TB/PPD immediately and again 90 days post-deployment
Provider referrals For all Determine need from documentation or exam ensure referral to PCM for PDH-CPG based care
Integrate DD2796 and DD2766 Integrate all deployment health documents into permanent medical record mail copy or send electronic DD2796 to AMSA
55
Redeployment Reserve ComponentTask Additional
RC Medical Processing
Medical benefit/ entitlement benefit Ensure each RC soldier receives medical benefit/entitlement brief on www.pdhealth.mil/reservist/personnel and (http//www.defenselink.mil/ra/documents/family/demob.ppt)
Soldier completes DD Form 2697 All personnel released from AD (REFRAD) must complete MEDICAL ASSESSMENT, DD2697 (on pdhealth.mil website)
Health Record Review Provider reviews DD 2697 and other documentation to identify health problems that require additional follow-up
Soldier must actively decline medical exam Physical exam is part of DD2697 default is do the exam unless soldier declines
Complete routine demob medical processing Complete medical processing as in AD scenario refer to PCM as needed for PDH-CPG-based follow-up
LOD required Determine if Line of Duty (LOD) determination is required initiate LOD as needed
ADME requirement Determine if Active Duty Medical Extension is required to clear current health concerns.
Complete documentation Integrate all deployment health documents into permanent medical record mail copy or send electronic DD2796 to AMSA
56
RedeploymentNGO and Civilian, Non-Government
Personnel
  • Contractors non-federal workers
  • Covered under health insurance of their
    contracting company occupational medicine and PM
    only if part of contract
  • Private and network health care providers can get
    information about guideline-based care through
    help-line and website
  • Also Tricare network and VA providers can access
    info
  • NGO Personnel Policies
  • Red Cross, USO, and other non-government
    personnel are not included in the demobilization,
    medical processing, or follow-up medical care
  • Can be exceptions with Secretary of the Army
    designee status
  • Embedded journalists
  • A new population
  • Not a military health care beneficiary group

57
(No Transcript)
58
Redeployment Task Primary Care PDH-CPG DD 2796
Follow-up
  • 3. Task Primary Care PDH-CPG DD 2796 Follow-up
  • When Should follow ASAP from ID during demob
    process
  • Recommend NLT 7 days of reintegration, may need
    immediate
  • Sick call vs. appointment process for large
    groups
  • Who
  • Receptionist - Harmony
  • Medical screener/LPN SSG Whiskey or LPN Grace
  • Primary Care Manager Dr. Station
  • Tools
  • SF600 with screening question or stamp
  • Toolbox PDH Clinic Visit Desk Reference Card
  • DD Form 2844
  • Aids
  • Web site and algorithms ENVITE mnemonic
  • Prior training and role play of situations

59
Toolbox Reference Cards PDH Clinic Visit
  • Provides guidance for
  • training screeners about the
  • deployment-related question
  • How to ask the question
  • Emphasizes that deployment
  • is not necessary to have PDH
  • concerns
  • How to respond to patients
  • questions
  • Examples of deployments and
  • deployment-related concerns or
  • conditions

60
Optional DD Form 2844 - Post Deployment Medical
Assessment Form and Primer
  • Optional form for documenting
  • post-deployment medical evaluation
  • Form available and can be
  • be completed on line at
  • www.PDHealth.mil

Toolbox DD 2844 Primer
61
Redeployment Task Primary Care PDH-CPG DD
2796 Follow-up (cont.)
  • 3. Process Primary Care PDH-CPG DD 2796
    Follow-up
  • SSG Freedom reports, as instructed, to PC on 17
    May
  • Persistent cough, congestion fears SARS (Severe
    Acute Respiratory Syndrome)
  • SSG Guard reports to PC on same day, with same
    sx, concerned because of work at the airport
  • Greeted courteously by Receptionist, Harmony
  • Vignette

62
Redeployment Task Primary Care PDH-CPG DD 2796
Follow-up (cont.)
  • 3. Process Primary Care PDH-CPG DD 2796
    Follow-up
  • Medical screener/LPN SSG Whiskey or LPN Grace
  • Asks deployment-related vital sign
  • "Is your problem today related to a deployment?"
  • Marks yes on stamped SF600 (or pre-printed SF
    600 at TMC)
  • Alerts provider to yes response
  • Original DD Form 2796 in permanent medical record
  • Color coded forms or folders have been used
  • DD Form 2844 on follow-up appointment

63
Redeployment Task Primary Care PDH-CPG DD 2796
Follow-up (cont.)
  • 3. Process Primary Care PDH-CPG DD 2796
    Follow-up
  • Provider Dr. Station
  • Acknowledges that visit is deployment-related
  • Reinforces follow-up from DD2796 instructions
  • Express appreciation for service compassion for
    concerns
  • Stepped-risk communication model (see guideline)
  • ENVITE mnemonic for risk communication
  • Info on deployment risks (see PDHealth.mil web
    site)
  • Risk communication takes place throughout
    encounter, not just at end
  • Reviews DD2796 (and DD2844 on follow-up visit)
  • Evaluates chief complaint identifies
    established diagnosis
  • Viral respiratory infection (not consistent with
    SARS)

64
Stepped Risk CommunicationRecognized Disease
65
Redeployment Task Primary Care PDH-CPG DD 2796
Follow-up (cont.)
  • 3. Process Primary Care PDH-CPG DD 2796
    Follow-up
  • Provider Dr. Station
  • Documents deployment-related visit primary code
    V70.5_6
  • Documents disease-specific diagnosis as secondary
    code
  • Establishes follow-up appointment both IAW
    disease specific guideline and for PDH concern
    (30 minute PDH appt where DD Form 2844 is used)
  • Prior to follow-up Researches if SARS was a
    potential exposure in area of operations or
    during return trip for discussion in follow-up

66
Redeployment Task Primary Care PDH-CPG DD 2796
Follow-up (cont.)
  • 3. Process Primary Care PDH-CPG DD 2796
    Follow-up
  • Case Management Function
  • Adds PDH-CPG Patient to the tracking database
  • Ensures follow-up made
  • Provides additional patient educational
    materials, as requested by patient/provider
  • Quality controls coding

67
Redeployment Task Primary Care PDH-CPG
Definitive Diagnosis
  • 3. Definitive Dx Family Member 15 Jun 03
  • Patience Freedom brings 8 y/o son, Butch, to PC
  • Describes conflict with dad since return from
    Iraq son getting into fights at school
  • Ask screening question military vital sign
  • Document screening response and alert provider
  • Provider recognizes deployment-related nature
  • Provide effective risk communication
  • Refer to Behavioral Health provider
  • Document deployment V-code and family problem
    V-code
  • Follow-up, track, and manage case

68
Redeployment Task Primary Care PDH-CPG
Definitive Diagnosis (cont.)
  • 3. Definitive Dx Family Member
  • Key points to remember
  • Deployment-related problems not limited to
    service members or adults
  • Can be spouse, child, or retiree
  • Family affected by stress and also can be exposed
    to contaminants, bacteria, etc. brought back by
    soldier
  • Process remains the same

69
Redeployment Task Primary Care PDH-CPG
Definitive Diagnosis (cont.)
  • 3. Definitive Dx Key Points
  • Ensure risk communication in clinic contacts
  • Ask screening question military vital sign
  • Document screening response and alert provider
  • Provider recognizes deployment-related nature
  • Triage Identify definitive diagnosis
  • Provide effective risk communication
  • Document deployment V-code and disease diagnosis
    code
  • Follow-up, track, and manage case

70
ICD-9 Coding for Identifiable Disease
  • V70.5_ 6
  • Deployment-related visit
  • plus
  • Usual Disease Code

71
Asymptomatic Patient with Health Concerns
  • Expresses a health concern, but does not exhibit
    or describe any discernable illness or injury
  • Concerns related to
  • Illness
  • Vaccine or anticipated vaccine or meds
  • Exposure or anticipated exposure
  • An experience
  • News media coverage, internet, etc.
  • Can be service member or family member
  • Legitimate health care visit

72
Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment Asymptomatic Concerned (cont.)
  • Post-deployment Presentation 30 Jun 03
  • SSG Freedom presents to clinic
  • Describes concerns about DU, read article in
    paper
  • Saw armored vehicle blown-up, no wounds
  • Note on wounded processes
  • Tools
  • SF600 screening question
  • Toolbox Desk Reference Cards
  • DD Form 2844 on follow-up visit
  • Aids
  • Fact Sheets
  • PDHealth.mil web site and DHCC Deployment Health
    Daily News
  • Provider help-line 1-866-559-1627

73
Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment Asymptomatic Concerned (cont.)
  • Post-deployment, Asymptomatic Concerned
  • Process
  • SSG Whiskey/LPN Grace asks deployment-related
    screening question
  • Records yes, alerts provider to
    deployment-related visit
  • Provider expresses recognition to patient that
    the visit is deployment-related and reinforce
    decision to make a health care visit to discuss
  • Employs risk communication through stepped-care
    algorithm and ENVITE reminder

74
Stepped Risk CommunicationAsymptomatic Concerned
75
Worldwide Web Support forPost-Deployment Health
Carewww.PDHealth.mil
  • Information on all
  • deployments and
  • deployment cycle support
  • Specific diseases and
  • emerging health concerns
  • Web-navigable version of
  • the PDH-CPG
  • Online clinical tools
  • News and information library
  • Provider education and
  • training
  • Patient education

76
Deployment Health News
  • Email newsletter each
  • business day
  • Deployment-related news
  • articles
  • To subscribe, sign up at
  • www.pdhealth.mil/
  • nl_signup.asp

77
Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment Asymptomatic Concerned (cont.)
  • Summary Asymptomatic Concerned Key Points
  • Ensure risk communication in clinic contacts
  • Ask screening question military vital sign
  • Document screening response and alert provider
  • Provider recognizes deployment-related nature
  • Triage Identify Asymptomatic Concerned
  • Provide effective risk communication
  • Document patient education
  • Code V70.5_6 and V65.5
  • Research and 30 minute follow-up
  • Follow-up, track, and manage case

78
Medically Unexplained Symptoms (MUS)
  • Physical symptoms that provoke care-seeking, but
    have no clinically determined pathogenesis after
    an appropriately thorough diagnostic evaluation.
  • V70.5_ 6 plus ICD-9-CM MUS Code 799.89
  • Note ICD-9-CM Guidelines 2005 changed MUS code
    from 799.8 to 799.89.

79
Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment MUS
  • Post-deployment Presentation 15 Sept 03
  • SSG Freedom presents to clinic
  • Describes fatigue, headache, cant sleep,
    episodic rash
  • Symptoms on and off since return from Iraq
  • Tools
  • SF600 screening question
  • Toolbox Desk Reference Cards
  • DD Form 2844 on initial follow-up visit
  • Assessment and outcome instruments
  • SF36, PHQ, PDCAT
  • Aids
  • PDHealth.mil web site
  • Provider help-line 1-866-559-1627

80
Assessment and Outcome Tools
SF-36v2
  • SF-36v2 - Health Survey
  • Short measure of health-
  • related quality of life
  • PHQ - Patient Health
  • Questionnaire
  • Screens and monitors status
  • of common health conditions
  • PDCAT - Post Deployment
  • Health Clinical Assessment Tool
  • Measures certain aspects of
  • physical and mental health
  • Useful in following post-
  • deployment health conditions

PHQ
PDCAT
Forms and primers on www.PDHealth.mil
81
Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment MUS (cont.)
  • Process Medically Unexplained Symptoms
  • Ask screening question document alert
    provider recognize deployment-related
  • Use DD Form 2844 to capture more thorough history
  • Conduct clinical assessment
  • Administer functional assessment and outcome
    measure
  • Use effective risk communication and patient
    education materials

82
Stepped Risk CommunicationMedically Unexplained
Symptoms
Concerned, Unexplained Symptoms
  • Symptom-based patient education
  • Consult specialty care
  • Deployment Health Clinical Center consult
  • Consider Specialized Care Program for chronic
  • symptoms

Concerned, Asymptomatic
Concerned, Recognized Disease
  • Education
  • Web and Print
  • 30 minute
  • Follow-up appt
  • Disease-centered
  • patient education
  • Disease prognosis
  • Disease treatment
  • options

Unconcerned, Recently Deployed
Routine rapport trust-building
83
VA/DoD Medically UnexplainedSymptoms (MUS)
Clinical Practice Guideline
84
Medically Unexplained SymptomsPatient Education
Brochures
Available from the DHCC web site www.PDHealth.mil
Available from the MEDCOM web site
www.qmo.amedd.army.mil
85
Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment MUS (cont.)
  • Process Medically Unexplained Symptoms
  • Refer to MUS-specific Clinical Practice Guideline
  • Also at www.pdhealth.mil, Supporting Guidelines
  • Additional guidelines Depression, PTSD
  • Consider specialty care and second opinions
  • Always follow-up, even when referral to specialty
    care case management
  • Case Management
  • 30-minute appt for patient education and RC
  • Tele-consult DHCC
  • For unresolved concerns Consider referral to
    DHCC Specialized Care Program for rehabilitative
    care
  • Dont forget to code V70.5_6 Deployment-related
    visit plus 799.89 (Ill-defined condition)

86
DHCC Clinical CareSpecialized Care Programs(SCP
Tracks I and II)
  • Intensive, 3-week, multidisciplinary,
    rehabilitative
  • program for patients with deployment-related
    chronic illness
  • or Medically Unexplained Symptoms or
    post-operational stress
  • Available to all military members and family
    members who
  • continue to have problems after going through
    PDH-CPG based
  • care at local MTF and meet admission criteria
    (e.g., ambulatory,
  • capable of some exercise) (Track II for
    military members only)
  • Behavioral and self-care strategies and
    treatments include
  • Physical conditioning
  • Patient education
  • Counseling
  • Nutritional counseling
  • Occupational therapy
  • Relaxation training
  • Cognitive-behavioral therapy
  • Exposure therapy

87
Deployment Health Clinical Center Resource Center
  • DHCC Helpline for Clinicians/Providers
    (Administrative and clinical consultation
    - Mon-Fri 0730-1630)
  • US Toll Free  1-866-559-1627
  • Local No. 202-356-0907 (DSN 642)
  • Outside US DSN 312-642-0907
  • DoD Helpline for Veterans and Family Members
    (Patient information, referral, advocacy -
    Mon-Fri 0730-1630)
  • US Toll Free 1-800-796-9699
  • Local No.  202-782-3577 (DSN 662)
  • From Europe Toll Free  00800-8666-8666
  • Outside US DSN  312-662-3577
  • Email Questions
  • pdhealth_at_amedd.army.mil

88
Post-Deployment Task Primary Care PDH-CPG Eval
and Treatment MUS (cont.)
  • Summary Medically Unexplained Symptoms
  • Ask screening question military vital sign
  • Document screening response and alert provider
  • Use DD Form 2844
  • Provider recognizes deployment-related nature
  • Evaluate clinically refer to MUS CPG
  • Use assessment and outcome tools on pdhealth.mil
  • e.g., SF36, PHQ, PDCAT
  • Provide effective risk communication
  • Code V70.5_6 and 799.89
  • Research, 30 minute follow-up
  • Consult specialty care DHCC phone consult
    DHCC rehabilitative care for chronic MUS
  • Follow-up, track, and manage case

89
Pre-Deployment Phase of Cycle Task Primary
Care PDH-CPG Evaluation and Treatment
  • Pre-deployment 1 Nov 03
  • SSG Reserve is on reserve drill at Ft Carson
    scheduled to be deployed again in
    60 days
  • Reports to Primary Care describes flashbacks of
    last combat, inability to sleep, intrusive
    thoughts of seeing friend killed in tank
    explosion, easily startled, drinking a lot lately
  • Tools
  • All previous PDH-CPG tools
  • PTSD screening scale (on web site)
  • Risk communication very important at this point
  • Process Follow Definitive Diagnosis Algorithm
    (A3)
  • Refer to VHA nearer to his home for treatment
  • Key
  • MUS is not the same as MH (mental health) concern
  • PDH-CPG applies throughout the Deployment Cycle
  • VA offers Reserve and Guard care 2 years
    post-deployment
  • Vet Centers available for family counseling

90
Post Traumatic Stress DisorderChecklists, Primer
and CPG
  • Assesses trauma-related distress
  • Self-administered
  • 3 Versions
  • Civilian Version (PCL-C)
  • Military Version (PCL-M)
  • Stress Specific Version (PCL-S)
  • Available on www.PDHealth.mil

PCL-M
PTSD CPG
PCL Primer
91
Deployment Health AssessmentForms and Primers
DD Form 2795
  • DD Form 2795, Pre-Deployment
  • Health Assessment
  • Reviewed by a credentialed provider
  • for positive responses
  • DD Form 2796, Post-Deployment
  • Health Assessment
  • Face to face assessment by trained health
  • care provider (physician, physician
  • assistant, nurse practitioner, independent
  • duty corpsman/medical technician)
  • Available on www.PDHealth.mil

DD 2795 Primer
DD Form 2796
DD 2796 Primer
92
PDH-CPG Training Briefs
  • Produced by DHCC
  • 7 video modules
  • from 7-12 minutes
  • Developed for
  • medical providers
  • and support staff
  • Posted on DHCC
  • web site
  • www.PDHealth.mil

Table of Contents
  • Introduction
  • Primary Care Screening
  • Primary Care Evaluation
  • Management Follow-up
  • Health Risk Communication
  • Coding and Documentation
  • PDHA

93
Deployment Health ClinicalTraining Series
  • Produced by DHCC
  • 11 modules from
  • 17-47 minutes
  • Video, script, slides
  • Developed for medical
  • providers and support
  • staff
  • Posted on DHCC web site
  • www.PDHealth.mil

Table of Contents
  • PDH-CPG
  • Introduction/Overview
  • Screening/Evaluation
  • Management/Follow-up
  • Risk Communication
  • Coding/Documentation
  • PDHA Process
  • Emerging Health Concerns
  • Suicide
  • Malaria
  • Depleted Uranium
  • Leishmaniasis
  • Vaccine Safety

94
Unlesswars are fought solely by machines, the
human cost of warfare will remain high. The
troops mustbe given a commitment for all
necessary care for war-related illness.
Straus SE Lancet 1999 353162-3
95
Questions, Information,Assistance
DoD Deployment Health Clinical Center
Walter Reed Army Medical Center Building 2,
Room 3G04 6900 Georgia Ave, NW Washington, DC
20307-5001 E-mail
pdhealth_at_na.amedd.army.mil Website
www.PDHealth.mil
202-782-6563 DSN662
Provider Helpline 1-866-559-1627
Patient Helpline 1-800-796-9699
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